Review of Cornea

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5 Little Things Before 2013

Get your contracts, codes and fees in order before the year is out.
By John Rumpakis, O.D., M.B.A., Clinical Coding Editor


I realize that it’s only November and we have a full month to go before 2012 is out and 2013 is upon us—but there are a few tasks that probably need your consideration or attention.

1. Get Updated Agreements
Create a form letter that requests a current copy of your provider agreement (i.e., contracts) from each carrier. Send it to the plan administrator or to the provider relations department. It’s important to request an updated copy every year, because your carriers have the ability to unilaterally change your provider agreement without notification. So, unless you have the most recent version, you’re in the dark about your—and their—contractual obligations.

2. Organize Your Contracts
Create a notebook that indexes all of your provider agreements for all of your insurance carriers, both refractive and medical. Divide your notebook into two sections—one for refractive carriers and another for medical carriers. Organize copies of your contracts in your notebook in alphabetical order.

3. Update Your CPT Codes
Educate yourself and your staff about the most up-to-date code definitions and characteristics.
One of the most astonishing things that I encounter when working with practices is that they use CPT codes that are either obsolete or inappropriate for the care delivered. An online or cloud-based system (such as provides easy access to real-time CPT code definitions, changes and proper use protocols. Likewise, be sure to update your EMR and routing slips with the new CPT codes.

4. Take Stock of ICD Codes
Update your ICD-9 codes for 2013, and begin a training program for implementing the upcoming ICD-10 codes.

One of the most common reasons for denied medical claims is the use of an incomplete or obsolete diagnosis code. So, it’s vital for your practice to stay updated on this information. The ICD codes can be revised and updated as frequently as every three months, with the annual update occurring on October 1 of every year.

Meanwhile, you should be preparing for the ICD-10 codes. Here is the timeline for the transition:

  • October 1, 2011: The last annual updates to both ICD-9-CM and ICD-10 code sets were made.
  • October 1, 2012/October 1, 2013: Limited code updates to both the ICD-9-CM and ICD-10 code sets to capture new technologies and diseases.
  • On October 1, 2014: Limited code updates to ICD-10 code sets to capture new technologies and diagnoses, but no updates to ICD-9-CM because it will no longer be used for reporting.
  • October 1, 2015: Regular updates to ICD-10 will begin.

5. Update Your Fees
While I can’t tell you how to set your fees specifically, I can tell you that most practices are leaving hard-earned revenues on the table because they haven’t evaluated their fee structure in an objective, analytical manner.

Perform an annual, semi-annual, quarterly or even monthly review and analysis of your fees.  Allowable reimbursements vary significantly by carrier—make sure to include all of your carriers in your analysis to evaluate how your pricing per CPT code stacks up. While this can be cumbersome, it is critical to your profitability. (You also can use a tool like the Fee Schedule Analyzer on, which allows you to automatically evaluate and update your fee structure.) 

As a rule, you shouldn’t charge less than your carriers are willing to pay. But, keep in mind that you have to charge every patient equally for the same CPT code, whether he or she pays out of pocket or uses an insurance plan.

When you pay attention to your professional service revenues, you’ll likely realize increases in both gross and net income. This is like getting “free money” because you’re simply increasing your reimbursements for professional services for the same work performed. That’s working smarter, not harder.

Disclosure: Dr. Rumpakis is the founder, developer and owner of and has a financial interest in it.

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